Change: Had enough?

The transition from winter to spring is one that I look forward to every year. Predictions for snowfall disappear from the forecast, trees and flowers are budding and blooming, and smell of fresh cut grass is just around the corner. Health care is going through a bit of a change these days as well. Have you seen the news? CVS is acquiring Aetna; Cigna is acquiring Express Scripts; Warren Buffet, Amazon and JP Morgan announced a health care collaboration, and last but not least, even Walmart is joining the fun with their recent interest in Humana. The change of seasons is predictable, but few among us anticipated these intriguing announcements in the health care arena.

Closer to home

While I’d love to dive into the implications of these massive shifts in health care alliances, dust of my crystal ball and pontificate about what this means for nephrology, I am sure I would miss the mark—and probably end up like my recent March Madness bracket. (Admit it, did you even know who the Retrievers and Ramblers were before the tournament started?) No, the change I want to review today is one a bit closer to home.

Earlier this year, the Medicare Payment Advisory Commission (MedPAC) voted overwhelmingly to replace MIPS. According to MedPAC, MIPS creates too much burden on physicians, and is unlikely to result in improvements in care. Joining the MedPAC chorus are concerns that MIPS may widen health care disparities. Citing experience with the recently retired Medicare physician value-based payment modifier (VM), concerns have been raised that providers caring for “sicker” patients, whether based on medical complexity or socioeconomic status, are inappropriately categorized as delivering lower quality. In a perspective entitled “How Value-Based Medicare Payments Exacerbate Health Care Disparities” published in JAMA last month, Rita Rubin highlights several sources who have jumped on this bandwagon. MIPS is a zero-sum game, where the bonuses collected by the winners are paid by extracting rent from the losers. If the assertions above are correct, proponents of this line of thinking would argue the system is penalizing those who care for the less fortunate.

Alternatives?

Of course, it’s easy to criticize the status quo. Should we scrap MIPS and the rest of the Quality Payment Program (QPP) less than 18 months in, and perhaps revert back to the SGR, PQRS, the VM, and our old “friend” meaningful use? Ditching MACRA without a viable alternative is a tall order. As I recall, the vote in the Senate in favor of MACRA was 92-8—a remarkable result in this day of partisan politics. MedPAC’s proposed MIPS replacement is something they refer to as a “voluntary value program.” This is basically a 2% withhold from your fee schedule with a possibility to earn it back. If you have a couple of minutes, I highly recommend reading Dr Gail Wilensky’s very well-written perspective about this proposal, published last week in the NEJM.

Advanced APMs

What’s often lost in these conversations is the recent success enjoyed by specialty-specific advanced alternative payment models (Advanced APMs). As a reminder, Advanced APMs represent the second arm of the QPP. Within the QPP, with rare exception, you are either subject to MIPS or you are a participant within an Advanced APM. In spite of its flaws (and trust me there are many), the ESCO model may be the poster child for specialty-specific APMs. And why not? Patients with ESRD are complex patients and they are very expensive to care for. Within a transactional fee-for-service world where you are paid more if you do more, there are no incentives—in fact, some would argue there are disincentives—to prevent avoidable hospital stays. One of the foundational requirements upon which Advanced APMs are based is the requirement for participants to take downside risk. Although anecdotal, I can tell you that in my experience, when providers have financial skin in the game, more attention is paid to avoidable hospitalizations.

While the experience was limited to 13 ESCOs, the year 1 performance was worth repeating. All 13 ESCOs managed to generate savings for the US taxpayer during the first year of the program. I know of no other CMMI “experiment” that can make the same claim.

Change

The US health care landscape is indeed changing and changing rapidly. It’s unclear what impact, if any, the recently announced diverse set of mergers and acquisitions will have on the practice of nephrology. Closer to home, the calls to dissolve MIPS strike me as a bit premature. I think the best we can hope for is a simplification of the daunting reporting requirements that MIPS physicians face today. On the Advanced APM front, my bet is the ESCO program will complete its five year run in spite of its flaws.

We are learning a lot along during this journey, but I truly hope the powers that be will do the right thing and make the PATIENTS Act a reality. While we wait, I plan to enjoy the departure of winter and spring’s arrival. I hope you do as well.

What are your thoughts about the changes we face today? Do you have any recommendations regarding how best to pursue the “quadruple aim”? Drop us a comment and join the conversation.

Terry Ketchersid, MD, MBA, practiced nephrology for 15 years before spending the past seven years at Acumen focused on the Health IT needs of nephrologists. He currently holds the position of Chief Medical Officer for the Integrated Care Group at Fresenius Medical Care North America where he leverages his passion for Health IT to problem solve the coordination of care for the complex patient population served by the enterprise.

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